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Methods of Documentation

Several methods of documentation are used to organize a nurse’s notes, sometimes referred to as progress notes. Decisions about which method to use may depend on the organization where you work, which sometimes specify certain methods. Otherwise, it is usually a matter of personal preference.

In this section, three main documentation methods are presented: charting by exception, narrative, and nursing process. Another method that is sometimes used to inform documentation is SBAR (Situation, Background, Assessment, and Recommendation), as discussed in a previous chapter, but this was typically designed to inform verbal communication.

Charting by exception. This method is not commonly used, but some specific units find it helpful. Typically, it involves charting when a finding is not normal. A specific setting will provide a list of normal ranges or normal activities, and you will only document a note if the client’s activities or your assessment findings are outside of the norms. For example, a normal finding may be no signs of infection on an incision: you would only document if the client exhibits signs of infection such as redness, swelling, or discharge.

Narrative involves chronological documentation that follows a storied format and sequential order. For example, you would document when the client’s symptoms first started, what they did to treat them, and how they responded to the treatment. A storied format involves attending to ‘what,’ ‘when,’ ‘who,’ and ‘how’ – what happened, when did it happen, who was involved, how the client responded, etc. For example: “8-year-old client fell off bike. Client’s mother indicated that he experienced a loss of consciousness for about 20 seconds, was confused when he awoke, and got a headache within 20 minutes. She brought him to the emergency, arrived within 30–40 minutes of the fall.” As you can see, this documentation note is both chronological and storied.

The nursing process is used to inform documentation in which the nurse focuses on the client’s issue/concern/problem, followed by the plan and action to address the issue, and an evaluation of how the client responded. This method is also called problem-focused documentation. Several approaches are used for this kind of documentation:

  • DAR (data, action, response)
  • APIE (assessment, plan, intervention, evaluation)
  • SOAP (subjective, objective, assessment, plan) and its derivatives including
  • SOAPIE (subjective, objective, assessment, plan, intervention, evaluation).

These methods share commonalities; see Table 8.

 

Table 8: Methods used to document the nursing process

DAR

APIE

SOAPIE

Comments

Data

Assessment

Subjective and objective data assessment

Assessment refers to your analysis of the available data. For example, it may include the health problem/issue and nursing diagnosis (e.g., risk for falls, risk for infection). Assessment guides the next steps in terms of planning and interventions.

Action

Plan and implementation/intervention

Plan and intervention

Action refers to what you did to address the problem (e.g., repositioning the client, providing pain medication).

Planning and intervention are similar to action. They may be combined or separated into different items: planning refers to realistic and measurable interventions to be implemented (e.g., education, mobility, safety interventions, vital sign frequency); intervention refers to what was done.

Response

Evaluation

Evaluation

Response and evaluation refer to the outcome of the intervention (did it work? how did the patient respond?)

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Documentation in Nursing: 1st Canadian edition by Jennifer Lapum, Oona St-Amant, Charlene Ronquillo, Michelle Hughes, and Joy Garmaise-Yee is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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